VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Christiansburg
201 Wheatland Court
Christiansburg, VA 24073
(540) 382-5200

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Sept. 20, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/20/2022 start: 1:30pm-3:34pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection The evidence gathered during the investigation supported the complaint of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Crystal B. Mullins, Licensing Inspector at 276-608-1067 or by email at crystal.b.mullins@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1090-A
Complaint related:	No
Description:	Based on review of resident records, the facility failed to have one resident assessed by an independent physician as hBased on review of resident records, the facility failed to have one resident assessed by an independent physician as having a serious cognitive impairment due to a primary diagnosis of dementia prior to the admission of a safe, secure environment. EVIDENCE: 1. Resident #1 was moved to the safe and secure unit on 6/10/22. The assessment for serious cognitive impairment was documented as completed on 6/15/22. 2. Progress note dated 6/10/22 states? Boss Matt was notified and voiced to put him in memory care for tonight to keep him safe until the physician is able to be reached tomorrow?. Having a serious cognitive impairment due to a primary diagnosis
Plan of Correction:	A review of all Memory Care resident records will be conducted to ensure that all Memory Care residents have an Assessment of Serious Cognitive A review of all Memory Care resident records will be conducted to ensure that all Memory Care residents have an Assessment of Serious Cognitive Impairment that demonstrates that the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The ED or designee will be re-educated on the regulation related to the requirement of an Assessment of Serious Cognitive Impairment prior to placement into the secured unit. Prior to an admission into the secured memory care unit, the ED or designee will audit pre-admission documentation for all new admissions to ensure that there is an Assessment of Serious Cognitive Impairment performed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician that demonstrates that the resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The audits will be conducted for each new admission for a period of 3 months.[SIC]
Standard #:	22VAC40-73-325-B
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to review and update fall risk ratings after a fall for one resident. EVIDENCE: 1. Resident #1 ha a UAI (Uniform Assessment Instrument) dated 7/16/22 which rates him for assisted living. A fall risk was completed on Resident #1 on 4/12/19. 2. Resident #1 had falls on the following dates: 1/15/22, 2/19/22, 4/3/22, 4/22/22, 4/26/22, 4/27/22, 6/5/22, and 9/3/22. There were no fall risks completed after the one dated 4/12/19.
Plan of Correction:	A fall risk completed was completed for Resident #1?s 9/3/22 fall on 10/3/22. A review of all resident?s clinical records who sustained falls for the month of 9/2022 forward will be reviewed to ensure appropriate fall risk ratings were completed. RMA staff will be trained to complete the post fall Fall Risk Rating at the time of the incident. The RCD or designee will review Fall incident reports with the ED or designee during Stand-Up Meetings each business day and ensure that the Fall Risk Ratings have been completed prior to closing the incident report in the electronic health record. The ED/designee will monitor all falls reported through the electronic health record weekly to ensure that a Fall Risk Rating was completed for each fall for 1 month, and then monthly for 2 months to ensure on-going compliance. [SIC]